Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosing and Delayed Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by eight medication administration errors out of twenty-six observed opportunities, resulting in a 30.77% error rate. For one resident with diagnoses including hydronephrosis, type two diabetes mellitus, and immunodeficiency, a registered nurse administered only one tablet of Cholecalciferol (Vitamin D3) 1000 IU, despite a provider order specifying five tablets (totaling 5000 IU) to be given once daily. This discrepancy was confirmed upon review of the provider order and by the Director of Nursing, who stated that the expectation was to administer the full ordered dose. Another resident, with diagnoses including type two diabetes mellitus with ketoacidosis, reduced mobility, and a need for personal care assistance, did not receive their scheduled 08:00AM medications on time. The registered nurse responsible for medication administration acknowledged that the medications were overdue, as indicated by the red status in the electronic health record, and attributed the delay to a high patient load. The facility's policy and staff interviews confirmed that medications should be administered within one hour of the scheduled time and in accordance with prescriber orders, which was not followed in these instances.